Cough-Induced Bilateral Internal Carotid Artery Dissection Complicated With Large Vessel Occlusion and Malignant Middle Cerebral Artery Syndrome

Cervical artery dissection (carotid artery and vertebral artery) is one of the important causes of cerebrovascular accidents, particularly in younger patients without traditional vascular risk factors. Coughing caused by respiratory tract infections can, in rare cases, lead to a vessel wall tear, potentially resulting in embolism. We present a 55-year-old man who came to the hospital with transient episodes of left arm weakness, dysarthria, and facial numbness, which progressed to left hemiparesis in three hours. A non-enhanced brain CT scan and cerebral angiography showed thrombus in M1 segment of the right middle cerebral artery (MCA) with extensive occlusion of the right internal carotid artery (ICA) with marked dissection of the cervical portion of the left ICA. He was initially treated with intravenous thrombolysis with alteplase, according to the hospital's protocol. His symptoms improved temporarily but he later developed a thrombus in the same vessel complicated by malignant MCA. We discuss the identification of carotid artery dissection, escalation, and management of the patient.